HESI RN
HESI Fundamentals
1. During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?
- A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing.
- B. The client tells the nurse that she does not have much of an appetite today.
- C. The nurse notes that there are numerous scatter rugs throughout the house.
- D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.
Correct answer: C
Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.
2. A 6-year-old child with sickle cell anemia presents to the emergency department with severe pain in the legs and abdomen. The child is crying and states that the pain is unbearable. What is the nurse’s priority action?
- A. Apply warm compresses to the painful areas
- B. Administer prescribed pain medication
- C. Encourage the child to drink fluids
- D. Monitor the child’s oxygen saturation
Correct answer: B
Rationale: In a sickle cell crisis, pain management is a priority to alleviate the child's suffering. Administering the prescribed pain medication is crucial to address the severe pain experienced by the child. Warm compresses, encouraging fluid intake, and monitoring oxygen saturation are important interventions but should follow the priority of pain management in this situation.
3. The client is preparing to discontinue the use of a sedative-hypnotic medication. Which instruction should the nurse include?
- A. “You may experience withdrawal symptoms; these are usually mild.”
- B. “The medication will need to be gradually tapered off.”
- C. “You should increase your caffeine intake to stay alert.”
- D. “There should be no change in your sleep patterns during discontinuation.”
Correct answer: B
Rationale: When discontinuing sedative-hypnotic medications, it is crucial to gradually taper them off to prevent withdrawal symptoms. Choice A is incorrect because withdrawal symptoms can be severe, not always mild. Choice C is incorrect as increasing caffeine intake can exacerbate sleep disturbances. Choice D is incorrect because changes in sleep patterns are expected during discontinuation of sedative-hypnotic medications.
4. Total Fertility Rate is at 6.2 births per woman in Zambia. This implies that:
- A. Zambian women will give birth to 6.2 children on average during their childbearing years.
- B. 6.2% of the time she will be pregnant during her childbearing years.
- C. 6.2% of her deliveries will not be successful.
- D. 6.2% of women will require medical intervention to become pregnant.
Correct answer: A
Rationale: A Total Fertility Rate of 6.2 means that a woman will give birth to an average of 6.2 children during her childbearing years. The correct answer is A as it accurately reflects the concept of Total Fertility Rate. Choice B is incorrect as it misinterprets the concept by equating it to a percentage of time being pregnant. Choice C is incorrect as it does not relate to the Total Fertility Rate but rather to the success rate of deliveries. Choice D is incorrect as it introduces the idea of medical intervention, which is not directly related to the Total Fertility Rate.
5. Which of the following are outcomes of an ectopic pregnancy EXCEPT?
- A. Tubal abortion
- B. Tubal rupture
- C. Intra-tubal bleeding
- D. Secondary abdominal pregnancy
Correct answer: D
Rationale: Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. Common outcomes include tubal abortion (spontaneous termination of ectopic pregnancy within the fallopian tube), tubal rupture (rupture of the fallopian tube leading to internal bleeding), and intra-tubal bleeding. Secondary abdominal pregnancy, on the other hand, is a rare occurrence and not a typical outcome of an ectopic pregnancy. It involves the implantation of a fertilized egg in the peritoneal cavity rather than the uterus.